An Exclusive Sneak Peak at the Physician Assistant Nutrition Fellowship

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Dr. Jennifer Harrington has literally traveled the world to help others receive quality healthcare. From the shores of Malaysia to the mountains of Peru, this PA Doctor has touched thousands of lives. When she’s not building up Lincoln Memorial University’s newest PA program in Tampa, Florida, she’s making a difference as one of the newest PA Foundation Nutrition Outreach Fellows. Jennifer Harrington, DMS, MHS, PA-C recently met with a PA Doctor editor to talk about her experience in the Nutrition Outreach Fellowship. 

The PA Foundation Nutrition Outreach Fellowship

“I decided to pursue this fellowship because I’ve had a long-term interest in nutrition in general,” she says. “I really enjoy when patients have that ‘a-ha’ moment and they can take a step in a positive direction to really take charge of their own health and use nutrition or exercise or to make a positive impact on their health.”

The PA Foundation Nutrition Outreach Fellowship was designed “to provide a way for PAs, especially those with an interest in community leadership, to receive special training and resources on nutrition to both enhance their clinical practice and to give back to their healthcare peers and the community at large.”

In the Nutrition Fellowship, thirty Physician Associates (PAs) from across the country received training on the role of nutrition with a focus on type 2 diabetes, healthy aging, and wound healing.

Though she’s not currently in clinical practice, Dr. Harrington has a passion for helping others. These days she reaches patients by educating their healthcare providers. Her focus is on helping PAs to do the right thing. She has been a PA educator at LMU since 2010. 

Weight Loss and the PA Nutrition Fellowship

According to the CDC, obesity in America is on the rise. In 2010, about 30% of US adults were obese. That number rose to almost 42% in 2020. Being obese is not just bad for your health, it’s also expensive. Obese patients spent $1,800 more per year in healthcare contributing to over $170 billion of annual spending across the country. 

Dr. Harrington is well aware of the impacts of obesity on overall health including the relationship between weight and type 2 diabetes. She has been living and working in rural Appalachia for over a decade where obesity rates are especially concerning. The PA Foundation Nutrition Outreach Fellowship helped sharpen her skills at a time when obesity and diabetes run rampant.

Meeting Patients Right Where They’re At

“I feel like a lot of clinicians like to make their dietary or nutritional advice be one-size-fits-all. And it just can’t be because of the variations in our patient’s cultures, backgrounds, and habits. Providers really need to get to know where their patients are starting from in order to best advise them,” she says. 

“First, I would figure out what stage of change they’re in,” states Dr. Harrington. “Are they in a pre-contemplation or contemplation stage?” If a patient is ready to improve their eating habits, clinicians can start with a 24-hour diet recall. Making the assignment and reviewing it at the next appointment is another option.

When reviewing the 24-hour food log, Dr. Harrington looks at the different food groups as well as amounts of food and the mode of preparation. “A big thing that we might forget to ask about are liquids,” she adds. “How are they hydrating?” 

Other red flags to point out include foods with excess sugar or simple carbohydrates as well as fats. A lack of fresh fruits and vegetables is also concerning. Dr. Harrington notes that many studies have shown that a higher intake of fruits and vegetables tends to edge out the unhealthier fare.

Are Calorie Counts Still Recommended? 

Journaling is helpful, says Dr. Harrington, as it helps make patients aware of their own habits. “Many people don’t realize how much they’re eating or how little of the healthier foods they might not be getting.” A food journal brings awareness which is the first step toward making a change.

Setting Nutritional Goals for Patients  

While some people may like precise macronutrient goals, it’s not for everyone. Dr. Harrington doesn’t usually get that specific. “What I will do is look at those food journals and identify a couple of things and then ask: ‘Are you willing to change this?’”

Common sense changes are key. Maybe that mid-morning soda could be a glass of water. Or the late-night potato chips could be some raw vegetables and hummus. “Baby steps,” says Dr. Harrington. 

Are Artificial Sweeteners Good for Weight Loss and Those With Diabetes? 

There’s a lot we still don’t know about artificial sweeteners. While non-sugar or non-nutritive sweeteners don’t contain any calories, they may still affect insulin levels and are associated with increased body weight. A 2020 study in the Journal of Family Medicine and Primary care found that artificial sweeteners were also associated with insulin resistance. 

Dr. Harrington offers another perspective, “If you’re eating a lot of foods containing artificial sweeteners, then you’re probably not eating the right kinds of foods.” Artificial sweeteners are most often found in processed foods. Go natural when possible. “Natural sources of sugar and fiber are almost always going to be better than the processed alternative,” says Dr. Harrington. A 2019 study in Current Diabetes Reports also suggests that natural alternative sweeteners like Stevia and monk fruit may be a better option than artificial sweeteners like sucralose and aspartame.

Offering Practical Suggestions to Improve Health and Nutrition

So how do you help a patient who just doesn’t know what they should be eating? You might talk about avoiding soda and processed foods just to have them respond, “That’s all I’ve ever eaten.” How do you help someone make meaningful change?

“You can’t just tell somebody to avoid something. It’s essential to provide a replacement that’s viable, cost-effective, and be something that they’re willing to do,” states Dr. Harrington. “So, for example, if somebody’s having a frozen burrito and orange juice for breakfast every morning, that’s a lot of sugar. So I might recommend something like oatmeal and a piece of fruit and maybe replacing that orange juice with some other kind of beverage that’s not as caloric and sugar-filled.” 

Time and time again, the DASH diet proves to be one of the best ways to address both blood pressure as well as weight. Experts also recommend a Mediterranean diet to improve heart health.

How to Get Patients to Drink More Water

Have you ever had a patient say, “I can’t drink water. It’s too plain for me”? Dr. Harrington hears that a lot. “I encourage patients to get used to water slowly.” Fruit-infused water, tea, vegetable juice, and kombucha can all be used to help patients ease into better hydration practices.

It’s also important to teach patients to start reading nutrition labels, notes Dr. Harrington. She specifically recommends that we pay attention to sugar and sodium content as well as fiber. Added sugars should be kept as low as possible. 

Using Nutrition to Help Heal Diabetic Foot Wounds

Good nutrition is essential to proper wound healing. One article specifically mentions vitamin A to enhance cytokine release; bromelain, and amino acids to prevent prolonged inflammation, and vitamin C to enhance neutrophil migration and lymphocyte activation. Vitamin C also aids in collagen synthesis while glucosamine enhances hyaluronic acid production. Zinc is required for DNA and protein synthesis.

Dietary protein is essential to wound healing and meat isn’t the only place to get it. According to Dr. Harrington, other good protein sources include whole grains like quinoa or beans and legumes like soybeans and lentils. Dairy can be another valuable source of dietary protein. 

Is Red Meat Bad?

Red meat consumption is another controversial topic. It’s loaded with wound-healing and satiating protein but has been linked to colon cancer and heart disease. A 2019 meta-analysis in Circulation found that substituting red meat with high-quality plant protein sources led to more favorable changes in blood lipids. 

Making Better Nutrition a Family Matter

Patients will be more successful when they can make lasting changes. But in order for changes to last, there needs to be buy-in from the family.

Dr. Harrington recommends what she calls the “power bowl” to please even the fussiest eater. “It’s a type of meal where there are lots of options and everybody can kind of pick and choose their own foods based on what they prefer.” Also known as Buddha bowls, they combine a protein source with a complex carbohydrate and a variety of toppings or sauces. 

A basic power bowl could consist of these grains, veggies, and lean protein:

Grains (and starchy vegetables) 

  • Brown rice
  • Quinoa
  • Farro
  • Sweet potatoes
  • Corn

Veggies:

  • Broccoli
  • Onions
  • Peppers
  • Cucumbers
  • Tomatoes

Lean Protein:

  • Chicken
  • Turkey
  • Fish
  • Eggs
  • Chickpeas 

Your power bowl certainly doesn’t have to be limited to these options! If you need a little more help, check out Kristen Sczebel’s Power Bowls: 100 Perfectly Balanced Meals in a Bowl. Another practical resource to educate patients about new ways of eating is The Mediterranean Diet for Beginners.

How to Deal with Picky Eaters

Every family has one and it’s not always a child. The key to dealing with a picky eater is in providing options. Dr. Harrington has picky eaters in her family and she has found that while they sometimes shy away from variety, it’s almost easier to feed them because, once they find it, they’ll eat that same healthy option day after day. 

When is it Time to Consult a Registered Dietician?

In an ideal world, every insurance plan would cover at least some amount of nutrition counseling. Coverage is abysmal, however. When payers refuse to permit an RD referral, Dr. Harrington recommends looking into programs at your local hospital or Federally Qualified Health Center (FQHC) that might provide free nutrition or cooking classes for diabetics or those with other medical conditions.

Healthy Eating at Every Age

Dietary needs shift as we age. Getting sufficient calories often becomes a primary goal. As our senses dull, we drink less and less water. We also tend to add more salt to enhance flavor. Dr. Harrington adds that “Some of my biggest concerns are inadequate protein. There are a lot of frail, older patients who don’t take in enough calories, maybe not enough fluid, and they’re getting too much sodium in their meals.” Adding heart-healthy fats such as olive oil can help increase total calories. 

Not Even Doctors and PAs Always Eat Perfectly

During one of the nutrition lectures put on by the PA Foundation Nutrition Fellowship, clinicians were asked to do their own 24-hour diet recall. “We estimated the protein and vitamin needs we would need for wound healing. And really, none of us did very well. Most of the group were younger and still didn’t have the nutrition it would take to heal a wound effectively.” Most of the Fellows learned that they were protein deficient. 

Dr. Harrington recommends about 1.5 grams of protein per kilogram of body weight per day for optimal wound healing. “When we talk about wound healing, we’re thinking about glutamine and arginine especially. We also need sufficient vitamin B12, vitamin C, and vitamin E. Zinc is the most evidence-based mineral for wound healing benefits,” she says. 

So Long Food Pyramid, Hello My Plate: Changing Nutrition Advice

Dr. Harrington recounts one of the most memorable moments from the Nutrition Fellowship as the opportunity to create meals based on the USDA’s My Plate considering different cultural backgrounds. “I thought that was really interesting because a lot of times as providers, we’re in this box and we think about our own cultural background and believe that this is probably what everybody eats. But we don’t often think about different cultures and how to tailor that education for them.” Dr. Harrington encourages clinicians to consider culture as an essential part of a discussion on nutrition.

My Plate focuses on fruits and vegetables while the foot pyramid was largely based on grains.

Another practical recommendation is to become a “perimeter shopper”. Explain that when they go to the grocery store, patients should try and stay out of the aisles as much as possible–that’s where all the boxed and canned foods are. By sticking to the perimeter of the grocery store, they’re going to end up in the shopping where food is likely to be less processed.

Dr. Harrington also recommends teaching patients about the glycemic index and how different foods affect blood sugar levels. “A sweet potato is not a bagel,” she says, “even though they’re both carbohydrates.” The glycemic index rates foods from 0-100 with the higher numbers having a greater impact on blood glucose. Blueberries (GI 53), for example, have less impact on blood sugar than watermelon (GI 80). 

Fad Diets Come and Go: Avoid Them All

“The problem with fad diets,” says Dr. Harrington, “is most people who go on them will lose some weight initially but they’ll gain it right back. It’s not going to help them long term and it doesn’t affect longevity either.”

To improve our health, we need to focus on enduring lifestyle changes, not diets. Diets don’t last. Eating for better health is a marathon, not a sprint. Skipping whole food groups or excluding certain foods is just not sustainable. Dr. Harrington stresses the importance of finding those foods that are also enjoyable to the patient but are also better for them. Making a few small changes can be more successful than attempting a complete overhaul.

“Studies have shown if patients can replace as little as 3% of the foods that impact them negatively, they can make a difference in their health,” states Dr. Harrington. “They can reduce cholesterol, reduce blood pressure, and they will live longer. It’s the little things that count. It doesn’t have to be all-or-nothing.” 

Weight Loss is Not About Restriction and Avoidance

What is the key to weight loss? Eat less, move more? Dr. Harrington doesn’t think so. “I don’t like the ‘eat less method’ in general because I like to eat a lot and I come from a family who likes to eat a lot. I like to say ‘eat more of what you know is 100% good for you.’ If you can fill your body with as many nutrients as possible,” she says, “then you’re likely to be able to lose weight because you’ll feel full with what your body needs.” 

Besides being unsustainable, ultra-low calorie diets rarely work. “It’s a metabolism issue,” states Dr. Harrington. “They’ve taught their body that they’re in starvation mode and so the body adjusts to using fewer calories.” Very low calories diets don’t help establish healthier habits.

Intermittent fasting is a more recent trend that works for some people. It allows the emphasis to be on time-restricted eating rather than calorie or food restriction. But evidence shows that it’s not any more successful than other types of dieting. Improving insulin sensitivity may be a secondary benefit, however.

Weight Loss is More about Self-Regulation than Nutritional Acrobatics 

While it’s true that our food supply is just not what it used to be, we live lives that are much more hectic than before. We often forget about the psychological components of eating better and living a healthier lifestyle. 

Whether you’re using a structured weight loss program or going it alone, we’ll all be successful if we incorporate the following into our lives:

  • Goal setting – Make goals that are SMART: Specific, Measurable, Achievable, Relevant, and Time-Bound.
  • Self-monitoring – Make yourself accountable and keep some record of your intake and activity.
  • Learn about intuitive eating – Think about why you are reaching for something and eat only when you’re truly hungry.
  • Meal planning – Identify healthier options and prepare ahead of time.

For most people, the psychology of weight loss presents the biggest challenge. We know what we should be doing, but we struggle with the execution. A weight loss program focused on the psychology of weight loss, like Noom, can help address that. 

Noom targets long-term success through behavior change, not restrictive dieting. Just as no two people are the same, weight loss recommendations should never follow a one-size-fits-all approach. 

Preventing Chronic Disease by Eating Right

Weight management is surely an important benefit of proper nutrition but studies have shown that there are other benefits, too. For example, low-carb diets are shown to lower the risk of type 2 diabetes, heart disease, and some cancers.

When is the Best Time of Day to Eat?

There’s an old saying: “Eat breakfast like a king, lunch like a prince, dinner like a pauper.” But whether you’re practicing intermittent fasting or some other diet, there’s no convincing research that proves that “breakfast is the most important meal of the day.” 

Many studies evaluating intermittent fasting, for example, used a fasting period of at least 12 hours. This recent study in JAMA Internal Medicine specifically looked at a fasting period between 8 pm and 12 pm–meaning, no king-like breakfast.

Participants who fasted in the JAMA study did lose more weight than controls but these gains don’t seem to outlast competing diets at the one-year mark. 

TLDR: How to Lose Weight and Keep it Off

There is no single way to eat to lose weight and get healthy. Whether it’s low carb, intermittent fasting, or low fat, what matters is creating real enduring change. Stop drinking your calories, eat fewer processed foods, eat a little bit less, and adopt a healthier approach to eating.

One thought on “An Exclusive Sneak Peak at the Physician Assistant Nutrition Fellowship

  • September 18, 2022 at 11:02 am
    Permalink

    A great article, and naturally a great subject matter and issue for the patient community at large. Yet, personally and professionally I feel this type of fellowship is not ( in my view) relevant enough to incorporate into the post PA training realm for many reasons. Let me explain briefly.

    As a Surgical PA myself, I have consulted with nutrition-trained professional healthcare providers thoroughly trained in these areas serving these needs, namely: registered dieticians & endocrinologists.

    Why bring a hybrid clinician into the picture? As such, this should cause some concern in light of the lack of quality clinical training or availability of well-rounded precepting sites/rotations. In fact, many PA programs have a course in their curricula already addressing this.

    In my discussions with many “experienced” practicing PAs, most if not all of them have shared with me/whished their programs would have had one other course instead of nutrition or something to that effect. Plus, this would be in my view better suited for CME conferences, etc.

    Perhaps these educational resources could be allocated in other areas of medical care rather than overlap our clinical reach.

    Reply

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